Regulatory Joe

Preventing Pharmacy Template Objections (feat. Bryan Connole)

On this episode of Regulatory Joe, Joe Boyle is joined by Penstock’s Director of Plan Management, Bryan Connole, to dive into one of the biggest pain points in ACA regulatory filing: the pharmacy benefit template.
As Plan Year 2026 approaches, CMS and state agencies are tightening expectations—especially around prior authorization and template accuracy. Bryan shares what tripped up issuers last year, what tools are critical for success, and how internal misalignment (especially with PBMs and pharmacy teams) can derail your entire submission.
In this episode:
The top objection trends from Plan Year 2025
How to use CMS validation tools to avoid rework
Why cross-validation errors can still cost you—even if your template looks “clean”
What to expect from CMS as MPMS continues to evolve
Practical tips for internal coordination and compliance
Whether you're a seasoned filer or new to regulatory operations, this episode offers actionable insight to help you stay compliant, avoid objections, and file with confidence.
🎧 Listen now and future-proof your pharmacy benefit template strategy.

Reconciliation & Validation Strategies for ACA Plan Year 2026

In this episode, Regulatory Joe walks through the critical roles of reconciliation and validation in preparing ACA plans for the 2026 plan year.
Joe covers:
How to balance required CMS changes with strategic updates
What’s new in MPMS and CMS templates
Why treating draft templates as final saves time
Tips to align cross-functional teams and avoid submission rework
This episode is a must-listen for issuers and compliance teams looking to streamline filings and reduce last-minute surprises.

CMS is Moving Plan and Benefit Justification Forms to MPMS

A major change is coming for health plan issuers—CMS is restructuring how Plan and Benefit Justification Forms are handled.
Starting in 2026, issuers will no longer upload Justification Forms alongside their Plan and Benefit Templates. Instead, CMS will generate them post-submission through the MPMS portal, limiting issuer control and introducing new timing challenges.
In this episode, we break down:
How the new MPMS Justification Form process works
What issuers need to do to prepare for compliance changes
Why early validation and version control will be critical moving forward
#CMSRegulations #HealthPlans #MPMS #PlanSubmission #HealthcareCompliance

2026 NBPP: What Health Plans Need to Know

🚨 The 2026 Notice of Benefit and Payment Parameters (NBPP) is here! What does it mean for health plans?
In this episode of Regulatory Joe, we break down the latest ACA compliance updates for 2026, including key changes in AV calculations, special enrollment periods, state-based marketplace transitions, and income verification requirements. With CMS moving up the timeline for finalizing regulations, issuers have more time than ever to strategize—but also more details to analyze.
Key Topics Covered:✔️ The impact of the finalized 2026 NBPP on health plan filings✔️ CMS’s latest approach to AV calculator updates✔️ Special Enrollment Periods (SEPs) and subsidy expansion✔️ What new call center standards mean for issuers✔️ How state-based marketplaces (SBMs) are evolving
🔗 For more insights, visit: regulatoryjoe.co

Navigating Risk Adjustment in 2025: A Guide for Health Plans

Join Joe Boyle, President of Regulatory Solutions at Penstock, as he breaks down CMS’s risk adjustment and user fee updates for benefit year 2025. This episode is your go-to guide for navigating the evolving regulatory landscape.
Here’s What You’ll Learn:
How CMS’s use of 2019–2021 data impacts 2025 submissions
The role of the American Rescue Plan in shaping membership trends and user fees
Key strategies for issuers entering new markets
Tips for compliance when serving AI/AN populations
Why predictive modeling is the future of risk adjustment
Whether you’re an established issuer or entering a new market, this episode is packed with actionable insights and practical recommendations to help you stay compliant, optimize processes, and prepare for the future of risk adjustment.
🎧 Listen now and make sure your team is ready for the 2025 submission season. Subscribe to Regulatory Joe for updates on regulatory filing for health plans, compliance tips, and more.

SBM-FPs Explained: What Health Plans Need to Know

SBM-FPs Explained: What Health Plans Need to Know
What are state-based marketplaces operating on the federal platform (SBM-FPs), and why are they becoming a popular choice for states? In this episode, Joe Boyle breaks it all down.
Learn the fundamentals of SBM-FPs, including how they operate, why states choose them, and the financial and operational implications for health plans. Joe also explains the transition process to standalone state-based marketplaces, the role of enhanced direct enrollment in maintaining a seamless member experience, and how carriers can align strategies to navigate these changes.
Whether you're preparing for an SBM transition or want to better understand these hybrid models, this episode provides valuable insights for health plan professionals.
Listen now to stay informed, and don’t forget to like, share, and subscribe!

Navigating RBIS in 2025: Essential Tips for Health Plans

In today’s episode of Regulatory Joe, we’re diving into the 2025 Rates and Benefits Information System (RBIS) updates, highlighting what health plans need to know to ensure accurate and compliant submissions.
📌 Key Takeaways:
The new four-window CMS schedule and how to stay ahead of critical deadlines
Updated URL submission criteria and best practices for mapping and validation
Tips for ensuring data accuracy and avoiding common RBIS submission errors
And more!
🔔 Subscribe for more regulatory insights and health plan updates!

What Health Plans Need to Know About the AV Calculator

In today’s episode of Regulatory Joe, we’re taking listeners through the 2025 Actuarial Value (AV) calculator, a tool that ensures plans meet standards for each metallic tier.
📌 Key Takeaways:
Consistent AV ranges for 2025 across all metallic tiers, with no major changes
Early testing with the draft AV calculator to stay on track with compliance
Best practices for version control and documentation when running the AV calculator
And more!
🔔 Subscribe for more regulatory insights and health plan updates!

How the 2024 Election Could Shape the Future of the Affordable Care Act

In this episode of Regulatory Joe, we break down the critical changes to Healthcare.gov that will reshape health plans in 2025. From streamlined enrollment to simplified plan selection, we dive into how these updates will impact issuers and plan operations in both federally facilitated and state-based marketplaces.
📌 Key Takeaways:
How the election results could reshape federal and state control over ACA marketplaces
The future of American Rescue Plan (ARP) insurance subsidies
What will happen with the newly released draft of the 2026 NBPP
And more!
🔔 Subscribe for more regulatory insights and health plan updates!

How Healthcare.gov 2025 Changes Will Impact Your Health Plan Strategy

In this episode of Regulatory Joe, we break down the critical changes to Healthcare.gov that will reshape health plans in 2025. From streamlined enrollment to simplified plan selection, we dive into how these updates will impact issuers and plan operations in both federally facilitated and state-based marketplaces.
📌 Key Takeaways:
Consistent user experience across Healthcare.gov and state exchanges
Simplified plan selection to reduce confusion for enrollees
Best practices for testing and syncing plan data
And more!
🔔 Subscribe for more regulatory insights and health plan updates!